Form D-400 - Individual Income Tax Return - 2016 Page 2
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1
2Last Name (First 10 Characters)
Tax Year
Your Social Security Number
Page 2
2016
D-400
Be sure to sign and date your return below.
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16. Tax Credits (From Form D-400TC, Part 3, Line 20 - You must attach
16.
00
Form D-400TC if you enter an amount on this line.)
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17.
00
17.
Subtract Line 16 from Line 15.
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If you certify that no Consumer
18.
18. Consumer Use Tax (See instructions.)
00
Use Tax is due, fill in circle.
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19.
19. Add Lines 17 and 18.
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20.
North Carolina
a.
Your tax withheld
b.
Spouse’s tax withheld
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Income Tax Withheld
00
00
If you claim a
21.
Other Tax Payments
a.
2016 estimated tax
b.
Paid with extension
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partnership payment
on Line 21c or S
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corporation payment
on Line 21d, you must
c.
Partnership
d.
S Corporation
attach a copy of the
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NC K-1.
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22.
22.
Amended Returns Only - Previous payments (See Amended Returns in instructions.)
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If amount on
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23.
Total Payments - Add Lines 20a through 22.
Line 25 is
23.
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negative, fill in
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circle.
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24.
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24.
Amended Returns Only - Previous refunds (See Amended Returns in instructions.)
Example:
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25.
00
25.
Subtract Line 24 from Line 23.
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26.
a. Tax Due - If Line 19 is more than Line 25, subtract Line 25 from Line 19.
26a.
(If Line 25 is negative, see instructions.)
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b. Penalties
c. Interest
(Add Lines 26b
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and 26c and
enter the total
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26d.
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on Line 26d.)
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e. Interest on the underpayment of estimated income tax
Exception to
26e.
00
(See instructions and enter letter in box, if applicable.)
underpayment
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$
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of estimated
27.
Add Lines 26a, 26d, and 26e.
tax
27.
Pay This Amount -
You can pay online. See instructions.
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28.
Overpayment - If Line 19 is less than Line 25,
28.
00
subtract Line 19 from Line 25.
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When filing an amended return, see instructions.
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29.
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29.
Amount of Line 28 to be applied to 2017 Estimated Income Tax
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30. Contribution to the N.C. Nongame and Endangered Wildlife Fund
30.
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31.
Contribution of overpayment to the N.C. Education Endowment Fund
31.
00
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32.
Add Lines 29, 30, and 31.
32.
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33.
Subtract Line 32 from Line 28. This is the Amount To Be Refunded.
33.
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For direct deposit, file electronically.
I certify that, to the best of my knowledge, this return is accurate and complete.
If prepared by a person other than taxpayer, this certification is based on all
information of which the preparer has any knowledge.
Your Signature
Date
Paid Preparer’s Signature
Date
Spouse’s Signature (If filing joint return, both must sign.)
Date
Preparer’s FEIN, SSN, or PTIN
Home Telephone Number (Include area code.)
Preparer’s Telephone Number (Include area code.)
If REFUND mail
N.C. DEPT. OF REVENUE
If you ARE NOT due a
N.C. DEPT. OF REVENUE
FOR ORIGINAL RETURNS ONLY
P.O. BOX R
refund, mail return, any
P.O. BOX 25000
return to:
RALEIGH, NC 27634-0001
payment, and D-400V to:
RALEIGH, NC 27640-0640
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